III.B. Overview of the State - Delaware - 2024
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Delaware is a small mid-Atlantic state located on the eastern seaboard of the United States. Geographically, the state's area encompasses only 1,982 square miles, ranking Delaware 49th in size among all states. Delaware is bordered by New Jersey, Pennsylvania and Maryland, as well as the Delaware River, Delaware Bay, and Atlantic Ocean. Centrally located between four major cities, Wilmington, the state’s largest urban center, is within an hour’s drive to Baltimore, MD and Philadelphia, PA and withing two hours driving distance from New York City and Washington, D.C.
Delaware's population as of July 1, 2021, was 1,018,396, according to the Census.
Delaware's population increased by 2.9% from 2020.
The First State was above the national growth rate of 7.4%, ranking 12th among all states in population growth rate from 2010 to 2020 and first among Northeast and Mid-Atlantic states. According to estimates from the U.S. Census Bureau, in 2022, 68% of Delaware residents were White and 24% were Black. The Hispanic population is steadily increasing, from 8.7% in 2013 to 10.1% in 2022. About 20.8% of Delawareans are children under the age of 18 and 5.3% were under the age of five.
Of Delaware's three counties, New Castle County, in the northern third of the state, is the largest in population with about 575,494 residents or about 57% of the state's total population. New Castle County has a large population of African American residents (nearly 27%) and within the city of Wilmington, the state's largest concentration of African American residents (about 57% of the city's population). New Castle County also has a large population of Hispanic residents, 11%. Kent County, home to the state’s capital of Dover, has an estimated 186,946 residents (64% White and 28% Black). For Sussex County, which includes very rural areas as well as coastal resort towns, the 2022 population was approximately 255,956 (83% White, 12% Black). Like New Castle, Sussex County also has a growing Hispanic population, estimated at 9.6% for 2022.
In 2020, statewide, it is estimated that there were about 185,176 women of childbearing age and over 250,000 children and adolescents aged 0-21 years of age. Data shows 10,792 births for 2020 and preliminary data shows 10,504 births for 2021. According to 2020-2021 combined years of data 21.1% have special healthcare needs (National Survey of Children’s Health/NOM 17.1).
Economic Indicators
In Delaware, 17.3 percent of children lived in poverty in 2017-2021, which remained stable with 17.2 percent in 2016- 2020. The highest rates are among those children aged 0-4 at 20.7%. According to Kids Count in Delaware, one in ten Delaware children in single mother households live in poverty. From 2017-2021, 11.1% of children in poverty were living in a single female householder compared to 4.4 living with a married couple. The median family income in 2021 was $82,100 for all Delawareans, the median family income for non-Hispanic white was $102,200 and $55,200 for Black or African American.
In 2020, 47.9% of all births were to unmarried women. In 2020, 34 percent of births were to single non-Hispanic white women, a slight increase from 32 percent in 2002. The percentage of births to single Hispanic women increased from 56 percent in 2002 to 62 percent in 2020. Unmarried non-Hispanic black women had the highest percentage of births from 2002 to 2020, remaining stable at approximately 70 percent during this time. (Delaware Health Statistics, 2020). As of 2022, an average of 61,155 households per month received food assistance through Delaware's Supplemental Nutrition Assistance Program (SNAP). (KIDS Count in Delaware, 2023).
Availability of Health Providers
Although Delaware is a relatively small state, disparities exist between its three counties regarding healthcare access. Access to health care services poses an issue for many uninsured, underserved and otherwise at-risk populations in Delaware. A myriad of factors affect access to health care, including lack of health insurance, lack of providers, an overall mal distribution of providers, etc. The Health Resources and Services Administration/Bureau of Health Workforce designated the following as Health Professional Shortages Areas (HPSAs). Regardless of their location, Federally Qualified Health Centers (FQHCs) are also automatically designated as HPSAs. In addition, many of the state correctional facilities are designated as HPSAs.
New Castle County:
- 4 Primary Care HPSAs
- 1 Dental HPSA
Kent County in its entirety is a:
- Medically Underserved Population
- Primary Care HPSA
- Dental HPSA
Sussex County in its entirety is a:
- Medically Underserved Area
- Primary Care HPSA
- Dental HPSA
- Mental Health HPSA
Services for CYSHCN
In Delaware, Children and Youth with Special Health Care Needs (CYSCHN) are served by the Birth to Three Program for infants and toddlers aged 0-3 and by evidence-based home visiting program services. The mission of the Birth to Three Early Intervention System is to enhance the development of infants and toddlers with or at risk for disabilities or developmental delays, and to enhance the capacity of their families to meet the needs of their young children. Child Development Watch (CDW) is the statewide early intervention program under the Birth to Three Early Intervention System. The CDW program provides developmental assessments of children birth to 3 years of age and service coordination for developmental services and therapies. CDW is a collaborative effort with staff from the Division of Public Health, the Department of Services for Children, Youth and Their Families, the Department of Education and the Alfred I. DuPont Hospital for Children (the only children’s hospital in Delaware) working together to provide early intervention to young children with special health care needs and their families.
The Children and Youth with Special Health Care Needs Director (CYSHCN) sits in the Division of Public Health’s Maternal and Child Health Bureau in the Family Health Systems Section. This position is essential as it functions to bolster and cultivate family and professional partnerships by working closely with families and family-led organizations. Delaware’s Birth to Three system works in coordination with the CYSHCN Director who oversees the Newborn Metabolic and Hearing Screening programs to ensure policies and procedures are in place for appropriate and timely receipt of needed intervention services. Delaware’s Family SHADE is a collaborative alliance of family partners and organizations committed to improving the quality of life for children and youth with special health care needs, and their caregivers, by connecting families and providers to information, resources and services; advocating for solutions to recognized gaps in services; and supporting its member organizations. Family SHADE is contractually lead by our Parent Information Center. In 2021, Family SHADE developed a process to award mini grants to community organizations to implement small place-based interventions to drive innovation and if proven effective brought to scale. Parent Information Center selected two community-based organizations to receive an award in 2022 and awarded four more community agencies a mini-grant this year.
Context for Title V within the State
Governor John Carney took office as Delaware’s 74th Governor in January 2017. Governor Carey heads the Executive Branch of state government in Delaware. Within the Executive Branch, the Delaware Department of Health and Social Services (DHSS) is a cabinet-level agency and is led by Secretary Molly Magarik. The Delaware Department of Health and Social Services is one of the largest agencies in state government. DHSS has 11 divisions and employs more than 4,000 individuals in a wide range of public service jobs. In one way or another DHSS affects almost every citizen in our great state. Our divisions provide services in the areas of public health, social services, substance abuse and mental health, child support, developmental disabilities, long-term care, visual impairment, aging and adults with physical disabilities, state service centers, management services, financial coaching, and Medicaid and medical assistance. The Department includes three long-term care facilities and the state's only public psychiatric hospital, the Delaware Psychiatric Center.
The Division of Public Health (DPH) is one of the largest divisions within DHSS and home to Title V, the agency is responsible for planning, program development, administration, and evaluation of maternal and child health (MCH) programs statewide. DPH was mostly recently led by Karyl T. Rattay, MD, MS, FAAP. FACPM who served as the Division Director for thirteen years. Currently, Dr. Elizabeth Brown is the interim director who also fills the Medical Director role for the Division of Medicaid and Medical Assistance. DPH remains steadfast to it mission, which is to protect and promote the health of all people in Delaware. Because Delaware does not have county or local health departments, DPH administers both state and local public health programs. Within DPH, the Family Health Systems (FHS) section has direct oversight of Title V, including the Children and Youth with Special Health Care Needs (CYSHCN) program.
Authority and regulatory charges for the Division of Public Health come from Title 16 of the Delaware Administrative Code, which governs health and safety. Specific to Family Health, the code includes regulations for operation of a Birth Defect Surveillance and Registry Program and an Autism Surveillance and Registry Program, both of which are funded in part by Title V. The Delaware Healthy Mother and Infant Consortium (DHMIC) is also established in code and is charged with coordinating efforts to prevent infant mortality and improve the health of women of childbearing age and infants in the State. Last year, the DPQC was formally established in Delaware Code and signed by the Governor during a virtual press conference in July 2020. Data collection and analysis is crucial to the DPQC’s efforts to improve the care and outcomes of DE’s women and their babies. The foundation of the collaborative is to share current data to use for benchmarking and QA/QI, identify best standards of care/protocols, realignment of service providers and service systems, continuing education of professionals and increasing public awareness of the importance of perinatal care. As such, our Title V Program works closely with the DHMIC to align our priorities and strategies as much as possible. We also have regulations in Title16 for school-based health centers which were codified in 2012, and subsequently regulations were established and updated in 2017. The Newborn Hearing and Metabolic Screening Programs, which are not primarily funded by Title V, but work in close coordination with the program are also established in the Title 16 code.
As of January 1, 2023, DPH was charging the birth facilities and midwives $135.00 per newborn for the newborn metabolic screening including lab and follow up services. The DPH contracts with A.I. duPont Children’s Hospital to administer the statewide program which includes both the program and laboratory services. A.I. duPont Children’s Hospital currently sub-contracts with Perkin Elmer to provide the laboratory services. Since outsourcing the program in 2018, the program has not increased the $135 fee. The Delaware Newborn Screening Advisory Committee meets at least three times a year and is a governor appointed body. The Advisory Committee members, DPH and AI. duPont spent quite a bit of time discussing the last few years discussing and voting on necessary changes including the elimination of the mandated second screen, how long blood spots should be stored and expanding the newborn screening panel. All these items, eliminating the second screen, timeline for specimen collection and the length of time bloodspot cards are stored were approved by the Advisory Committee and all birthing facilities were included the process. The Advisory Committee also voted on and provided a recommendation to the DPH Division Director to add four additional conditions, Pompe Disease, Muccopolysaccharidosis Type I (MPS I), X-Linked Adrenoleukodystrophy (X-ALD) and Spinal Muscular Atrophy (SMA) to Delaware’s screening panel. With the DPH Director’s approval, the additional conditions were added to the panel January 1, 2020. The program drafted the revisions needed to update the regulations to reflect the changes approved by the Board to change the timeline for storage of the specimens and collection of the specimens, the updated regulations were approved. The program also drafted changes to revise the legislative code which was approved during this most recent legislative session.
Current Priorities of the Division of Public Health
The Division of Public Health 2019-2023 Strategic Plan provides a clear and proven path for the division to continue to lead the state’s public health system. DPH is embarking on the Public Health 3.0 approach. Public Health 3.0 refers to a new era of enhanced and broadened public health practice that goes beyond traditional public health department functions and programs. Cross-sectoral collaboration is inherent to the Public Health 3.0 vision. We are collaborating across multiple sectors and leveraging data and resources to address policies as well as social, environmental, and economic conditions that affect health and health equity. We spent the better part of eight months re searching and analyzing our existing goals, strategies, and data; examined current national and local public health challenges; and considered future public health challenges. As a result, we have identified five strategic priorities, of which our new strategic plan is based: Promote Healthy Lifestyles; Improve Population Health and Reduce Health Care Costs; Achieve Health Equity; Reduce Substance Use Disorder and Overdose Deaths. The DPH is doubling its efforts to work collaboratively alongside Delaware state agencies and external stakeholders to address the immediate and long-term health consequences of substance use disorder and violence in communities. To tackle these complicated issues, DPH sees its role as providing prevention expertise, as well as technical assistance related to evidence based population health practices.
DPH staff will actively implement this strategic plan by improving our services, participating in robust workforce development activities, and practicing the LeadQuest 10 Principles of Personal Leadership.
Public Health has a unique lens. Our guiding principles call upon us to engage in population-based activities to strengthen community-based public health. Research continues to tell us that while 95 percent of our health care dollars are spent on acute care, these dollars account for only 10 percent of improvements to our health status. For sustainable results, our future efforts must include collaborating with communities to improve their ability to identify the most important determinants of health, to develop strategies to address them, and to implement those strategies. This strategic plan is evidence of our commitment to working strategically with our partners to achieve our vision of healthy people in healthy communities. Final updates were made and the DPH Division Director formally adopted the DPH 2019-2023 Strategic Plan on January 1, 2019. The Strategic Plan remains active until the end of the 2023. We believe once a permanent Division Director is place, work on a new Strategic Plan will begin.
Simultaneously, the Division engaged in maintaining its accreditation status by the Public Health Accreditation Board (PHAB). As an accredited public health agency, over the last four years we have made continuous progress. We report on that progress in annual reports to the PHAB. The Division of Public Health officially begun the journey to become reaccredited in January 2020 and we were able to acquire an extension on our submission deadline due to COVID. Once again, we assembled DPH PHAB Domain Teams and have begun organizing to develop and collect required reaccreditation documents. Like our first accreditation run, we compared the 12 PHAB Domains national public health service standards with public health services we provide in Delaware. These PHAB standards are based on the long-standing 10 Essential Public Health Services. The DPH Domain Teams met and developed narratives and capture documents describing how we implement public health services in Delaware in preparation for our submission. Our application was submitted and several DPH staff participated in interviews with the PHAB accreditation board in July 2022.
All areas within Domains 1-12 were identified as met, however there were some provided narratives or documents that were identified as not fully meeting the criteria but did not impact the overall domain score. The Office of Performance Management is reviewing these so adjustments can be made going forward.
Findings and Areas of excellence regarding MCH related work:
- DPH identifies and addresses health inequities through studies such as The State of Our Union: Black Girls in Delaware and The Healthy Women Healthy Baby program.
- DPH, in partnership with Delaware lawmakers, informs the public of the health implications of specific laws, e.g., SB-201 would lower infant mortality.
- DPH ensured programs and strategies use evidence-based practices (as available). One example is the Delaware Contraception Now program.
The findings, goals, and strategies that are part of both the Delaware SHIP and DPH’s strategic plan was intentionally factored into the Title V needs assessment process, with the goal of leveraging the results of these comprehensive planning efforts. We believe the input gathered from professional MCH stakeholders, families, and community members through surveys, focus groups, and interviews will reinforce the priorities of healthy lifestyles; population health; reducing health care costs; achieving health equity; and addressing substance use disorder and overdose deaths.
In Delaware, there is an increased effort to address health disparities and with good reason. Here are just a few examples of the disparities that exist within our state.
- Infant Mortality. The annual infant mortality rate for 2020 was 5.5 per 1,000 live births as compared to 5.4 per 1,000 for the U.S. The five-year infant mortality rate (2016-2020) was 6.5 per 1,000 (11.6 per 1,000 for Black non-Hispanics and 3.8 per 1,000 for White non-Hispanics). The five-year Black infant mortality rate decreased from 12.6 per 1,000 (2012-2016) to 11.6 per 1,000 live births (2016-2020) while the five-year White infant mortality rate decreased from 4.6 per 1,000 (2012-2016) to 3.8 per 1,000 live births (2016-2020). The five-year Black to White disparity ratio was about 3 times.
- Breastfeeding. According to Pregnancy Risk Assessment and Monitoring System (PRAMS) 2012-2021 data, the percentage of women who ever breastfed increased by 12% from 79.2% in 2012 to 88.6% in 2021 and currently breastfeeding (i.e., at the time of survey) increased by 23% from 48.8% in 2012 to 60.1% in 2021 among women with a recent live birth. There were differences in breastfeeding rates by race and ethnicity. For instance, based on PRAMS data, the 2021 prevalence of ever breastfed among Black non-Hispanics was 85.0% as compared to 88.0% among White non-Hispanics, 91.4% among Hispanics, and 96.7% among other races non-Hispanic. Similarly, the 2021 prevalence of currently breastfeeding (or at the time of survey) among Black non-Hispanics was 48.1% as compared with 64.4% among White non-Hispanics and 57.7% % among Hispanics, and 71.9% among other races non-Hispanic.
- Teen Births. The teen birth rate in the U.S. in 2020 was 15.4 per 1,000 females aged 15-19 years and the corresponding teen birth rate in Delaware in 2020 was 14.6 per 1,000 females aged 15-19 years. Between 2014 and 2020, the teen birth rate in Delaware declined by approximately 29.5 % (2014: 20.7 per 1,000 females aged 15-19 years). The disparity ratio in teen birth rates was 4.5 times for Black teens (27 per 1,000 females aged 15-19 years) and 5.2 times for Hispanic teens (31 per 1,000 females aged 15-19 years) to White teens (6 per 1,000 females aged 15-19 years). Despite the racial disparities, Delaware has made great, long-term strides in improving the teen birth rates among White non-Hispanic, Black non-Hispanic, and Hispanic teens through several population-based health interventions. In fact, between 1991 and 2020, the teen birth rate declined by approximately 85 % for White non-Hispanics, decreased by approximately 86 % for Black non-Hispanics, and decreased by 72 % for Hispanics.
- Overall, Health. As per the National Survey of Children’s Health (NSCH), in 2020-2021, an estimated 89.8% of Delaware children reported to be in excellent/very good health (White non-Hispanic: 93.4%; Black non-Hispanic: 86.0%; Hispanic: 82.1%; and Other non-Hispanic : 94.1%) as compared with 90.2% in the U.S. (White non-Hispanic: 93.4%; Black non-Hispanic: 86.0%; Hispanic: 85.8%; and Other: 91.1%). Health status varied by income status in Delaware like the U.S. overall. Health status improved with increased household incomes. For instance, in Delaware, 85.6% of children in households at 0-99% federal poverty level (FPL) indicated excellent/very good health as compared to 96.1% in 400% or greater FPL category.
- Overall, Health Women of Childbearing Age. According to Behavior Risk Factor Surveillance System (BRFSS) 2017-2021 data, the prevalence of good/excellent health among women of childbearing ages (18-44 years) increased from 83.3% in 2017 to 87.8% in 2021. With the exception of those who were high school graduate or GED, all other educational categories had higher prevalence of good/excellent health. Between 2017 (71.8%) and 2021 (88.4%) the percent of women of childbearing age with less than a high school education reported a 23% increase in good/excellent health as compared to those who attend college or technical school during 2017 (81%) and 2021 (86.2%), which had a modest increase of 6.4%. In 2021, 98.8% of women of childbearing age who identified as other race (non-Hispanic) reported good/excellent health as compared to 87.6% White (non-Hispanic), 82.1% Black (non-Hispanic), and 85.5% Hispanic women. During 2017-2021, there was over 11 percentage-point increase in good/excellent health among other race (non-Hispanic) and 9-percentage-point increase among Hispanic women as compared to 4 percentage-point increase among White (non-Hispanic) and less than half a percentage-point increase among Black non-Hispanic women.
- Smoking. According to Pregnancy Risk Assessment and Monitoring System (PRAMS) 2012-2021 data, the prevalence of smoking before pregnancy among women with a recent live birth declined by 46% from 27.2% in 2012 to 14.7% in 2021. Similarly, the prevalence of smoking during last three months of smoking among women with a recent live birth declined by 45% from 18.6% in 2012 to 10.3% in 2021. Lastly, the prevalence of smoking after pregnancy among women with a recent live birth declined by 38% from 13.3% in 2012 to 8.2% in 2021. However, the declines smoking prevalence was not uniform among different racial and ethnic groups. For instance, in 2012, over 1 in 3 (34.5%) White non-Hispanic women with a recent live birth smoked before pregnancy as compared to 1 in 4 (24.8%) Black non-Hispanic women. While the decline in smoking prevalence before pregnancy between 2012 and 2021 for White non-Hispanic was 49%, the decline among Black non-Hispanic women was 27.8%. Similarly, in 2012 17.7% of White non-Hispanic women reported smoking during the last three months of pregnancy as compared to 10.2% of Black non-Hispanic women. However, in 2021 10.2% of White non-Hispanic women reported smoking as compared to 8.3% of Black non-Hispanic women. While the decline in smoking prevalence during last three months was 42% among White (non-Hispanic) women, the decline among Black non-Hispanic women was 18%.
- Medical Home. As per the NSCH 2020-21 data, 46.3% of Delaware children received coordinated, ongoing, comprehensive care within a medical home as compared to 46.6% in the U.S. However, there were notable disparities with regards to children with medical home. For instance, in Delaware, 33.3% of Black non-Hispanic children (37.1% in the U.S.), 34.5% of Hispanic children (34.7% in the U.S.), 46.0% other non-Hispanic children (44.6% in the U.S.), and 57.3% of White non-Hispanic children (55.6% in the U.S.) indicated having a medical home. Further, there were differences due to special health care needs (CSHCN) status. For instance, 38.3% of children in Delaware with special health care needs indicating having a medical home as compared to 42.2% in the U.S.
It is clear from these examples that disparities exist across racial and ethnic groups, across ages, and across geographical boundaries. We know that many of these inequities are a result of the social determinants of health. Focus groups conducted for our needs assessment confirmed that our population experiences challenges with access to transportation to medical visits, access to healthy foods, and safe places to be active. There are language barriers and issues of cultural competency that prevent our Spanish-speaking citizens from being able to benefit from the programs and services that are available. And access to specialists and quality care is often limited by the county in which one lives.
The Delaware Division of Public Health has established health equity as a strategic priority for the entire division and released the second version of the Heathy Equity Guide for Public Health Practitioners and Partners. The Delaware Division of Public Health (DPH), the University of Delaware’s School of Public Policy & Administration, and other partners created the guide to help Delawareans better understand tools and strategies that promote health equity and support upstream population health approaches. The document is designed to assist all sectors which can include but are not limited to government, education, workplaces, private sector, nonprofit agencies, faith-based institutions, and health care settings address underlying causes of health inequities in communities and promote optimal health for all in Delaware. Every person deserves equal access to safe communities that foster opportunities to achieve optimal health and well-being. The Delaware Healthy Mothers and Infants Consortium continues to emphasize health equity and the social determinants of health, through highlighting the topic at Annual MCH Summit agendas, bestowing health equity awards to individuals and organizations to recognize efforts and launching an online Health Equity Action Center.
Recognizing the importance of social determinants of health, a place-based, community approach has been established as a key component. In 2019, a request for proposal was posted to solicit proposals for a backbone organization to manage what we are calling the Healthy Women Healthy Babies (HWHB) Zones project. This is the main focus of the Delaware Healthy Mother and Infant Consortium’s efforts as it aims to reduce the infant mortality rate. A comprehensive update on this initiative can be found in Well Woman application year narrative.
Health Care Reform Efforts in Delaware
Health care spending per capita in Delaware is higher than the national average. Historically, health care spending has outpaced inflation and the state’s economic growth. Health care costs consume 25% (or approximately 1 billion in FY 2017) of Delaware’s budget. Medicaid cost per capita and the growth in per capita spending have been above the national average. These challenges are not unique to Delaware – affordability is of equal concern to private employer sponsors of Commercial health insurance, as well as some consumer segments who have seen increases in deductibles, copays, and coinsurance. Delaware’s demographics and the percentage of our citizens with chronic conditions are key drivers of both spending and poor health outcomes. Delaware’s population is older and is aging faster than the national average – we will be the tenth oldest state by 2025. We are also sicker than the average state, with higher rates of chronic disease, in part driven by social determinants including poverty, food scarcity, and violence. The hospital landscape is more concentrated in Delaware than in most other markets, with just six acute care hospital systems across the state, with most populations relying on a single hospital for their care. Our hospital systems vary widely in both scale as well as operational efficiency. Primary care and some other physician specialties remain fragmented. Other physician specialties are concentrated. Behavioral health care is in short supply in some parts of the state. Increased demand for health care, as well as inefficiencies in the supply of health care, in combination lead to 25% greater historical spend per capita than the U.S., which itself has among the highest cost health care systems in the world. While we spend more on care, our investments have not led to better health or outcomes for Delawareans. We spend more than average, not to get better access or higher quality care, but simply to address the challenges of an older and sicker population.
After receiving federal grant monies through the Centers for Medicare and Medicaid’s State Innovation Model (SIM) project, Delaware has made a significant investment in transitioning to value-based payment models. Value based payment models enable collaboration between providers and health systems in addition to allowing a greater focus on keeping people healthy through improving primary care. This is vastly different from the traditional Fee for Service model that aligns payment for services with volume, regardless of patient outcomes and whether the overall population of the state is getting healthier. The State has supported these changes from a policy perspective by setting the expectation for Medicaid Managed Care Organizations (MCOs) and State Employee/Retiree Third-party administrators to offer and promote the adoption of value-based models.
In 2017, House Joint Resolution 7 authorizes the Department of Health and Social Services to establish a health care spending benchmark linked to growth in the overall economy. In 2018, the Department of Health and Social Services (DHSS), the Delaware Health Care Commission (DHCC) and the Delaware Economic and Financial Advisory Council (DEFAC) worked together to establish the spending and quality benchmarks. Insurers reported initial calendar year 2018 baseline data in 2019, giving them and the Department experience in collecting and reporting data, which is essential to the benchmarks and improving the process moving forward. Governor Carney established heath care spending and quality benchmarks in Executive Order 25, issued in November 2018. The spending benchmark is set on a calendar year by the Delaware Economic and Financial Advisory Council (DEFAC) Health Care Spending Benchmark Subcommittee.
The first spending benchmark went into effect on Jan.1, 2019, and was set at 3.8%. That spending benchmark was not met, as the finalized health care spending for 2019 grew at a rate of 5.8%. For calendar year 2020, the spending benchmark was set at a more ambitious target of 3.5%, which was met as the Total Health Care Expenditures (THCE) per-capita change from the prior year was estimated at -1.2%. Delaware’s spending benchmark is the year-over-year percentage change in total health care expenditures (THCE) expressed on a per capita basis. For Calendar Year 2021, the spending benchmark was set at a 3.25 percent growth rate. Delaware’s total Calendar Year 2021 THCE was approximately $9.1 billion. The per capita amount was $9,088, which represents a 11.2% year-over-year increase. The 11.2% per capita increase is significant, but this figure reflects Delaware’s health care market rebounding from the reduction in health care spending and utilization in Calendar Year 2020 caused by the COVID-19 pandemic.
The quality results for 2021 were similar to 2020. While Delaware made progress in some important measures, the report shows us there is still significant work to be done to improve the health of Delawareans in other areas.
Overview of Quality Results:
- Adult obesity: The benchmark for 2021 was to reduce the percentage of Delaware adults who are obese to 28.7%. The 2021 result: 33.9%; a decrease from 2020, but still 5.2 percentage points higher than the benchmark.
- Use of opioids at high dosages: The 2021 benchmark: 11.6%; the 2021 result: 9.6%. This is a positive observation.
- Opioid-related overdose deaths: The benchmark for 2021 was to reduce the mortality rate to 14.7 deaths per 100,000. The 2021 result: 48.1 deaths per 100,000. This is an increase from 2020.
- Emergency department utilization: The benchmark for 2021 was to reduce Emergency department utilization to 178 visits per 1,000. The 2021 result: 163 visits per 1,000. This is a positive observation.
- Persistence of beta-blocker treatment after a heart attack: The benchmark rate for 2021 was to increase the percentage of patients who receive beta-blocker treatment to 87.2% of commercial insurance patients and to 83.1% for Medicaid patients. The 2021 results: 88.5% for commercial insurance patients and 80.7% for Medicaid patients. While the Medicaid patients did not reach the benchmark, this is an improvement from the 2020 results of 78.1%.
- Statin therapy for patients with cardiovascular disease: The benchmark rate for 2021 was to increase the percentage of patients who receive statin therapy to 81.0% of commercial insurance patients and 63.8% for Medicaid patients. The 2021 results: 81.8% for commercial insurance patients; 66.1% for Medicaid patients. For both markets, results were better than the respective benchmark. To learn more about the health care spending and quality benchmarks, visit the Health Care Commission website.
Delaware is a small mid-Atlantic state located on the eastern seaboard of the United States. Geographically, the state's area encompasses only 1,982 square miles, ranking Delaware 49th in size among all states. Delaware is bordered by New Jersey, Pennsylvania and Maryland, as well as the Delaware River, Delaware Bay, and Atlantic Ocean. Centrally located between four major cities, Wilmington, the state’s largest urban center, is within an hour’s drive to Baltimore, MD and Philadelphia, PA and withing two hours driving distance from New York City and Washington, D.C.
Delaware's population as of July 1, 2021, was 1,018,396, according to the Census.
Delaware's population increased by 2.9% from 2020.
The First State was above the national growth rate of 7.4%, ranking 12th among all states in population growth rate from 2010 to 2020 and first among Northeast and Mid-Atlantic states. According to estimates from the U.S. Census Bureau, in 2022, 68% of Delaware residents were White and 24% were Black. The Hispanic population is steadily increasing, from 8.7% in 2013 to 10.1% in 2022. About 20.8% of Delawareans are children under the age of 18 and 5.3% were under the age of five.
Of Delaware's three counties, New Castle County, in the northern third of the state, is the largest in population with about 575,494 residents or about 57% of the state's total population. New Castle County has a large population of African American residents (nearly 27%) and within the city of Wilmington, the state's largest concentration of African American residents (about 57% of the city's population). New Castle County also has a large population of Hispanic residents, 11%. Kent County, home to the state’s capital of Dover, has an estimated 186,946 residents (64% White and 28% Black). For Sussex County, which includes very rural areas as well as coastal resort towns, the 2022 population was approximately 255,956 (83% White, 12% Black). Like New Castle, Sussex County also has a growing Hispanic population, estimated at 9.6% for 2022.
In 2020, statewide, it is estimated that there were about 185,176 women of childbearing age and over 250,000 children and adolescents aged 0-21 years of age. Data shows 10,792 births for 2020 and preliminary data shows 10,504 births for 2021. According to 2020-2021 combined years of data 21.1% have special healthcare needs (National Survey of Children’s Health/NOM 17.1).
Economic Indicators
In Delaware, 17.3 percent of children lived in poverty in 2017-2021, which remained stable with 17.2 percent in 2016- 2020. The highest rates are among those children aged 0-4 at 20.7%. According to Kids Count in Delaware, one in ten Delaware children in single mother households live in poverty. From 2017-2021, 11.1% of children in poverty were living in a single female householder compared to 4.4 living with a married couple. The median family income in 2021 was $82,100 for all Delawareans, the median family income for non-Hispanic white was $102,200 and $55,200 for Black or African American.
In 2020, 47.9% of all births were to unmarried women. In 2020, 34 percent of births were to single non-Hispanic white women, a slight increase from 32 percent in 2002. The percentage of births to single Hispanic women increased from 56 percent in 2002 to 62 percent in 2020. Unmarried non-Hispanic black women had the highest percentage of births from 2002 to 2020, remaining stable at approximately 70 percent during this time. (Delaware Health Statistics, 2020). As of 2022, an average of 61,155 households per month received food assistance through Delaware's Supplemental Nutrition Assistance Program (SNAP). (KIDS Count in Delaware, 2023).
Availability of Health Providers
Although Delaware is a relatively small state, disparities exist between its three counties regarding healthcare access. Access to health care services poses an issue for many uninsured, underserved and otherwise at-risk populations in Delaware. A myriad of factors affect access to health care, including lack of health insurance, lack of providers, an overall mal distribution of providers, etc. The Health Resources and Services Administration/Bureau of Health Workforce designated the following as Health Professional Shortages Areas (HPSAs). Regardless of their location, Federally Qualified Health Centers (FQHCs) are also automatically designated as HPSAs. In addition, many of the state correctional facilities are designated as HPSAs.
New Castle County:
- 4 Primary Care HPSAs
- 1 Dental HPSA
Kent County in its entirety is a:
- Medically Underserved Population
- Primary Care HPSA
- Dental HPSA
Sussex County in its entirety is a:
- Medically Underserved Area
- Primary Care HPSA
- Dental HPSA
- Mental Health HPSA
Services for CYSHCN
In Delaware, Children and Youth with Special Health Care Needs (CYSCHN) are served by the Birth to Three Program for infants and toddlers aged 0-3 and by evidence-based home visiting program services. The mission of the Birth to Three Early Intervention System is to enhance the development of infants and toddlers with or at risk for disabilities or developmental delays, and to enhance the capacity of their families to meet the needs of their young children. Child Development Watch (CDW) is the statewide early intervention program under the Birth to Three Early Intervention System. The CDW program provides developmental assessments of children birth to 3 years of age and service coordination for developmental services and therapies. CDW is a collaborative effort with staff from the Division of Public Health, the Department of Services for Children, Youth and Their Families, the Department of Education and the Alfred I. DuPont Hospital for Children (the only children’s hospital in Delaware) working together to provide early intervention to young children with special health care needs and their families.
The Children and Youth with Special Health Care Needs Director (CYSHCN) sits in the Division of Public Health’s Maternal and Child Health Bureau in the Family Health Systems Section. This position is essential as it functions to bolster and cultivate family and professional partnerships by working closely with families and family-led organizations. Delaware’s Birth to Three system works in coordination with the CYSHCN Director who oversees the Newborn Metabolic and Hearing Screening programs to ensure policies and procedures are in place for appropriate and timely receipt of needed intervention services. Delaware’s Family SHADE is a collaborative alliance of family partners and organizations committed to improving the quality of life for children and youth with special health care needs, and their caregivers, by connecting families and providers to information, resources and services; advocating for solutions to recognized gaps in services; and supporting its member organizations. Family SHADE is contractually lead by our Parent Information Center. In 2021, Family SHADE developed a process to award mini grants to community organizations to implement small place-based interventions to drive innovation and if proven effective brought to scale. Parent Information Center selected two community-based organizations to receive an award in 2022 and awarded four more community agencies a mini-grant this year.
Context for Title V within the State
Governor John Carney took office as Delaware’s 74th Governor in January 2017. Governor Carey heads the Executive Branch of state government in Delaware. Within the Executive Branch, the Delaware Department of Health and Social Services (DHSS) is a cabinet-level agency and is led by Secretary Molly Magarik. The Delaware Department of Health and Social Services is one of the largest agencies in state government. DHSS has 11 divisions and employs more than 4,000 individuals in a wide range of public service jobs. In one way or another DHSS affects almost every citizen in our great state. Our divisions provide services in the areas of public health, social services, substance abuse and mental health, child support, developmental disabilities, long-term care, visual impairment, aging and adults with physical disabilities, state service centers, management services, financial coaching, and Medicaid and medical assistance. The Department includes three long-term care facilities and the state's only public psychiatric hospital, the Delaware Psychiatric Center.
The Division of Public Health (DPH) is one of the largest divisions within DHSS and home to Title V, the agency is responsible for planning, program development, administration, and evaluation of maternal and child health (MCH) programs statewide. DPH was mostly recently led by Karyl T. Rattay, MD, MS, FAAP. FACPM who served as the Division Director for thirteen years. Currently, Dr. Elizabeth Brown is the interim director who also fills the Medical Director role for the Division of Medicaid and Medical Assistance. DPH remains steadfast to it mission, which is to protect and promote the health of all people in Delaware. Because Delaware does not have county or local health departments, DPH administers both state and local public health programs. Within DPH, the Family Health Systems (FHS) section has direct oversight of Title V, including the Children and Youth with Special Health Care Needs (CYSHCN) program.
Authority and regulatory charges for the Division of Public Health come from Title 16 of the Delaware Administrative Code, which governs health and safety. Specific to Family Health, the code includes regulations for operation of a Birth Defect Surveillance and Registry Program and an Autism Surveillance and Registry Program, both of which are funded in part by Title V. The Delaware Healthy Mother and Infant Consortium (DHMIC) is also established in code and is charged with coordinating efforts to prevent infant mortality and improve the health of women of childbearing age and infants in the State. Last year, the DPQC was formally established in Delaware Code and signed by the Governor during a virtual press conference in July 2020. Data collection and analysis is crucial to the DPQC’s efforts to improve the care and outcomes of DE’s women and their babies. The foundation of the collaborative is to share current data to use for benchmarking and QA/QI, identify best standards of care/protocols, realignment of service providers and service systems, continuing education of professionals and increasing public awareness of the importance of perinatal care. As such, our Title V Program works closely with the DHMIC to align our priorities and strategies as much as possible. We also have regulations in Title16 for school-based health centers which were codified in 2012, and subsequently regulations were established and updated in 2017. The Newborn Hearing and Metabolic Screening Programs, which are not primarily funded by Title V, but work in close coordination with the program are also established in the Title 16 code.
As of January 1, 2023, DPH was charging the birth facilities and midwives $135.00 per newborn for the newborn metabolic screening including lab and follow up services. The DPH contracts with A.I. duPont Children’s Hospital to administer the statewide program which includes both the program and laboratory services. A.I. duPont Children’s Hospital currently sub-contracts with Perkin Elmer to provide the laboratory services. Since outsourcing the program in 2018, the program has not increased the $135 fee. The Delaware Newborn Screening Advisory Committee meets at least three times a year and is a governor appointed body. The Advisory Committee members, DPH and AI. duPont spent quite a bit of time discussing the last few years discussing and voting on necessary changes including the elimination of the mandated second screen, how long blood spots should be stored and expanding the newborn screening panel. All these items, eliminating the second screen, timeline for specimen collection and the length of time bloodspot cards are stored were approved by the Advisory Committee and all birthing facilities were included the process. The Advisory Committee also voted on and provided a recommendation to the DPH Division Director to add four additional conditions, Pompe Disease, Muccopolysaccharidosis Type I (MPS I), X-Linked Adrenoleukodystrophy (X-ALD) and Spinal Muscular Atrophy (SMA) to Delaware’s screening panel. With the DPH Director’s approval, the additional conditions were added to the panel January 1, 2020. The program drafted the revisions needed to update the regulations to reflect the changes approved by the Board to change the timeline for storage of the specimens and collection of the specimens, the updated regulations were approved. The program also drafted changes to revise the legislative code which was approved during this most recent legislative session.
Current Priorities of the Division of Public Health
The Division of Public Health 2019-2023 Strategic Plan provides a clear and proven path for the division to continue to lead the state’s public health system. DPH is embarking on the Public Health 3.0 approach. Public Health 3.0 refers to a new era of enhanced and broadened public health practice that goes beyond traditional public health department functions and programs. Cross-sectoral collaboration is inherent to the Public Health 3.0 vision. We are collaborating across multiple sectors and leveraging data and resources to address policies as well as social, environmental, and economic conditions that affect health and health equity. We spent the better part of eight months re searching and analyzing our existing goals, strategies, and data; examined current national and local public health challenges; and considered future public health challenges. As a result, we have identified five strategic priorities, of which our new strategic plan is based: Promote Healthy Lifestyles; Improve Population Health and Reduce Health Care Costs; Achieve Health Equity; Reduce Substance Use Disorder and Overdose Deaths. The DPH is doubling its efforts to work collaboratively alongside Delaware state agencies and external stakeholders to address the immediate and long-term health consequences of substance use disorder and violence in communities. To tackle these complicated issues, DPH sees its role as providing prevention expertise, as well as technical assistance related to evidence based population health practices.
DPH staff will actively implement this strategic plan by improving our services, participating in robust workforce development activities, and practicing the LeadQuest 10 Principles of Personal Leadership.
Public Health has a unique lens. Our guiding principles call upon us to engage in population-based activities to strengthen community-based public health. Research continues to tell us that while 95 percent of our health care dollars are spent on acute care, these dollars account for only 10 percent of improvements to our health status. For sustainable results, our future efforts must include collaborating with communities to improve their ability to identify the most important determinants of health, to develop strategies to address them, and to implement those strategies. This strategic plan is evidence of our commitment to working strategically with our partners to achieve our vision of healthy people in healthy communities. Final updates were made and the DPH Division Director formally adopted the DPH 2019-2023 Strategic Plan on January 1, 2019. The Strategic Plan remains active until the end of the 2023. We believe once a permanent Division Director is place, work on a new Strategic Plan will begin.
Simultaneously, the Division engaged in maintaining its accreditation status by the Public Health Accreditation Board (PHAB). As an accredited public health agency, over the last four years we have made continuous progress. We report on that progress in annual reports to the PHAB. The Division of Public Health officially begun the journey to become reaccredited in January 2020 and we were able to acquire an extension on our submission deadline due to COVID. Once again, we assembled DPH PHAB Domain Teams and have begun organizing to develop and collect required reaccreditation documents. Like our first accreditation run, we compared the 12 PHAB Domains national public health service standards with public health services we provide in Delaware. These PHAB standards are based on the long-standing 10 Essential Public Health Services. The DPH Domain Teams met and developed narratives and capture documents describing how we implement public health services in Delaware in preparation for our submission. Our application was submitted and several DPH staff participated in interviews with the PHAB accreditation board in July 2022.
All areas within Domains 1-12 were identified as met, however there were some provided narratives or documents that were identified as not fully meeting the criteria but did not impact the overall domain score. The Office of Performance Management is reviewing these so adjustments can be made going forward.
Findings and Areas of excellence regarding MCH related work:
- DPH identifies and addresses health inequities through studies such as The State of Our Union: Black Girls in Delaware and The Healthy Women Healthy Baby program.
- DPH, in partnership with Delaware lawmakers, informs the public of the health implications of specific laws, e.g., SB-201 would lower infant mortality.
- DPH ensured programs and strategies use evidence-based practices (as available). One example is the Delaware Contraception Now program.
The findings, goals, and strategies that are part of both the Delaware SHIP and DPH’s strategic plan was intentionally factored into the Title V needs assessment process, with the goal of leveraging the results of these comprehensive planning efforts. We believe the input gathered from professional MCH stakeholders, families, and community members through surveys, focus groups, and interviews will reinforce the priorities of healthy lifestyles; population health; reducing health care costs; achieving health equity; and addressing substance use disorder and overdose deaths.
In Delaware, there is an increased effort to address health disparities and with good reason. Here are just a few examples of the disparities that exist within our state.
- Infant Mortality. The annual infant mortality rate for 2020 was 5.5 per 1,000 live births as compared to 5.4 per 1,000 for the U.S. The five-year infant mortality rate (2016-2020) was 6.5 per 1,000 (11.6 per 1,000 for Black non-Hispanics and 3.8 per 1,000 for White non-Hispanics). The five-year Black infant mortality rate decreased from 12.6 per 1,000 (2012-2016) to 11.6 per 1,000 live births (2016-2020) while the five-year White infant mortality rate decreased from 4.6 per 1,000 (2012-2016) to 3.8 per 1,000 live births (2016-2020). The five-year Black to White disparity ratio was about 3 times.
- Breastfeeding. According to Pregnancy Risk Assessment and Monitoring System (PRAMS) 2012-2021 data, the percentage of women who ever breastfed increased by 12% from 79.2% in 2012 to 88.6% in 2021 and currently breastfeeding (i.e., at the time of survey) increased by 23% from 48.8% in 2012 to 60.1% in 2021 among women with a recent live birth. There were differences in breastfeeding rates by race and ethnicity. For instance, based on PRAMS data, the 2021 prevalence of ever breastfed among Black non-Hispanics was 85.0% as compared to 88.0% among White non-Hispanics, 91.4% among Hispanics, and 96.7% among other races non-Hispanic. Similarly, the 2021 prevalence of currently breastfeeding (or at the time of survey) among Black non-Hispanics was 48.1% as compared with 64.4% among White non-Hispanics and 57.7% % among Hispanics, and 71.9% among other races non-Hispanic.
- Teen Births. The teen birth rate in the U.S. in 2020 was 15.4 per 1,000 females aged 15-19 years and the corresponding teen birth rate in Delaware in 2020 was 14.6 per 1,000 females aged 15-19 years. Between 2014 and 2020, the teen birth rate in Delaware declined by approximately 29.5 % (2014: 20.7 per 1,000 females aged 15-19 years). The disparity ratio in teen birth rates was 4.5 times for Black teens (27 per 1,000 females aged 15-19 years) and 5.2 times for Hispanic teens (31 per 1,000 females aged 15-19 years) to White teens (6 per 1,000 females aged 15-19 years). Despite the racial disparities, Delaware has made great, long-term strides in improving the teen birth rates among White non-Hispanic, Black non-Hispanic, and Hispanic teens through several population-based health interventions. In fact, between 1991 and 2020, the teen birth rate declined by approximately 85 % for White non-Hispanics, decreased by approximately 86 % for Black non-Hispanics, and decreased by 72 % for Hispanics.
- Overall, Health. As per the National Survey of Children’s Health (NSCH), in 2020-2021, an estimated 89.8% of Delaware children reported to be in excellent/very good health (White non-Hispanic: 93.4%; Black non-Hispanic: 86.0%; Hispanic: 82.1%; and Other non-Hispanic : 94.1%) as compared with 90.2% in the U.S. (White non-Hispanic: 93.4%; Black non-Hispanic: 86.0%; Hispanic: 85.8%; and Other: 91.1%). Health status varied by income status in Delaware like the U.S. overall. Health status improved with increased household incomes. For instance, in Delaware, 85.6% of children in households at 0-99% federal poverty level (FPL) indicated excellent/very good health as compared to 96.1% in 400% or greater FPL category.
- Overall, Health Women of Childbearing Age. According to Behavior Risk Factor Surveillance System (BRFSS) 2017-2021 data, the prevalence of good/excellent health among women of childbearing ages (18-44 years) increased from 83.3% in 2017 to 87.8% in 2021. With the exception of those who were high school graduate or GED, all other educational categories had higher prevalence of good/excellent health. Between 2017 (71.8%) and 2021 (88.4%) the percent of women of childbearing age with less than a high school education reported a 23% increase in good/excellent health as compared to those who attend college or technical school during 2017 (81%) and 2021 (86.2%), which had a modest increase of 6.4%. In 2021, 98.8% of women of childbearing age who identified as other race (non-Hispanic) reported good/excellent health as compared to 87.6% White (non-Hispanic), 82.1% Black (non-Hispanic), and 85.5% Hispanic women. During 2017-2021, there was over 11 percentage-point increase in good/excellent health among other race (non-Hispanic) and 9-percentage-point increase among Hispanic women as compared to 4 percentage-point increase among White (non-Hispanic) and less than half a percentage-point increase among Black non-Hispanic women.
- Smoking. According to Pregnancy Risk Assessment and Monitoring System (PRAMS) 2012-2021 data, the prevalence of smoking before pregnancy among women with a recent live birth declined by 46% from 27.2% in 2012 to 14.7% in 2021. Similarly, the prevalence of smoking during last three months of smoking among women with a recent live birth declined by 45% from 18.6% in 2012 to 10.3% in 2021. Lastly, the prevalence of smoking after pregnancy among women with a recent live birth declined by 38% from 13.3% in 2012 to 8.2% in 2021. However, the declines smoking prevalence was not uniform among different racial and ethnic groups. For instance, in 2012, over 1 in 3 (34.5%) White non-Hispanic women with a recent live birth smoked before pregnancy as compared to 1 in 4 (24.8%) Black non-Hispanic women. While the decline in smoking prevalence before pregnancy between 2012 and 2021 for White non-Hispanic was 49%, the decline among Black non-Hispanic women was 27.8%. Similarly, in 2012 17.7% of White non-Hispanic women reported smoking during the last three months of pregnancy as compared to 10.2% of Black non-Hispanic women. However, in 2021 10.2% of White non-Hispanic women reported smoking as compared to 8.3% of Black non-Hispanic women. While the decline in smoking prevalence during last three months was 42% among White (non-Hispanic) women, the decline among Black non-Hispanic women was 18%.
- Medical Home. As per the NSCH 2020-21 data, 46.3% of Delaware children received coordinated, ongoing, comprehensive care within a medical home as compared to 46.6% in the U.S. However, there were notable disparities with regards to children with medical home. For instance, in Delaware, 33.3% of Black non-Hispanic children (37.1% in the U.S.), 34.5% of Hispanic children (34.7% in the U.S.), 46.0% other non-Hispanic children (44.6% in the U.S.), and 57.3% of White non-Hispanic children (55.6% in the U.S.) indicated having a medical home. Further, there were differences due to special health care needs (CSHCN) status. For instance, 38.3% of children in Delaware with special health care needs indicating having a medical home as compared to 42.2% in the U.S.
It is clear from these examples that disparities exist across racial and ethnic groups, across ages, and across geographical boundaries. We know that many of these inequities are a result of the social determinants of health. Focus groups conducted for our needs assessment confirmed that our population experiences challenges with access to transportation to medical visits, access to healthy foods, and safe places to be active. There are language barriers and issues of cultural competency that prevent our Spanish-speaking citizens from being able to benefit from the programs and services that are available. And access to specialists and quality care is often limited by the county in which one lives.
The Delaware Division of Public Health has established health equity as a strategic priority for the entire division and released the second version of the Heathy Equity Guide for Public Health Practitioners and Partners. The Delaware Division of Public Health (DPH), the University of Delaware’s School of Public Policy & Administration, and other partners created the guide to help Delawareans better understand tools and strategies that promote health equity and support upstream population health approaches. The document is designed to assist all sectors which can include but are not limited to government, education, workplaces, private sector, nonprofit agencies, faith-based institutions, and health care settings address underlying causes of health inequities in communities and promote optimal health for all in Delaware. Every person deserves equal access to safe communities that foster opportunities to achieve optimal health and well-being. The Delaware Healthy Mothers and Infants Consortium continues to emphasize health equity and the social determinants of health, through highlighting the topic at Annual MCH Summit agendas, bestowing health equity awards to individuals and organizations to recognize efforts and launching an online Health Equity Action Center.
Recognizing the importance of social determinants of health, a place-based, community approach has been established as a key component. In 2019, a request for proposal was posted to solicit proposals for a backbone organization to manage what we are calling the Healthy Women Healthy Babies (HWHB) Zones project. This is the main focus of the Delaware Healthy Mother and Infant Consortium’s efforts as it aims to reduce the infant mortality rate. A comprehensive update on this initiative can be found in Well Woman application year narrative.
Health Care Reform Efforts in Delaware
Health care spending per capita in Delaware is higher than the national average. Historically, health care spending has outpaced inflation and the state’s economic growth. Health care costs consume 25% (or approximately 1 billion in FY 2017) of Delaware’s budget. Medicaid cost per capita and the growth in per capita spending have been above the national average. These challenges are not unique to Delaware – affordability is of equal concern to private employer sponsors of Commercial health insurance, as well as some consumer segments who have seen increases in deductibles, copays, and coinsurance. Delaware’s demographics and the percentage of our citizens with chronic conditions are key drivers of both spending and poor health outcomes. Delaware’s population is older and is aging faster than the national average – we will be the tenth oldest state by 2025. We are also sicker than the average state, with higher rates of chronic disease, in part driven by social determinants including poverty, food scarcity, and violence. The hospital landscape is more concentrated in Delaware than in most other markets, with just six acute care hospital systems across the state, with most populations relying on a single hospital for their care. Our hospital systems vary widely in both scale as well as operational efficiency. Primary care and some other physician specialties remain fragmented. Other physician specialties are concentrated. Behavioral health care is in short supply in some parts of the state. Increased demand for health care, as well as inefficiencies in the supply of health care, in combination lead to 25% greater historical spend per capita than the U.S., which itself has among the highest cost health care systems in the world. While we spend more on care, our investments have not led to better health or outcomes for Delawareans. We spend more than average, not to get better access or higher quality care, but simply to address the challenges of an older and sicker population.
After receiving federal grant monies through the Centers for Medicare and Medicaid’s State Innovation Model (SIM) project, Delaware has made a significant investment in transitioning to value-based payment models. Value based payment models enable collaboration between providers and health systems in addition to allowing a greater focus on keeping people healthy through improving primary care. This is vastly different from the traditional Fee for Service model that aligns payment for services with volume, regardless of patient outcomes and whether the overall population of the state is getting healthier. The State has supported these changes from a policy perspective by setting the expectation for Medicaid Managed Care Organizations (MCOs) and State Employee/Retiree Third-party administrators to offer and promote the adoption of value-based models.
In 2017, House Joint Resolution 7 authorizes the Department of Health and Social Services to establish a health care spending benchmark linked to growth in the overall economy. In 2018, the Department of Health and Social Services (DHSS), the Delaware Health Care Commission (DHCC) and the Delaware Economic and Financial Advisory Council (DEFAC) worked together to establish the spending and quality benchmarks. Insurers reported initial calendar year 2018 baseline data in 2019, giving them and the Department experience in collecting and reporting data, which is essential to the benchmarks and improving the process moving forward. Governor Carney established heath care spending and quality benchmarks in Executive Order 25, issued in November 2018. The spending benchmark is set on a calendar year by the Delaware Economic and Financial Advisory Council (DEFAC) Health Care Spending Benchmark Subcommittee.
The first spending benchmark went into effect on Jan.1, 2019, and was set at 3.8%. That spending benchmark was not met, as the finalized health care spending for 2019 grew at a rate of 5.8%. For calendar year 2020, the spending benchmark was set at a more ambitious target of 3.5%, which was met as the Total Health Care Expenditures (THCE) per-capita change from the prior year was estimated at -1.2%. Delaware’s spending benchmark is the year-over-year percentage change in total health care expenditures (THCE) expressed on a per capita basis. For Calendar Year 2021, the spending benchmark was set at a 3.25 percent growth rate. Delaware’s total Calendar Year 2021 THCE was approximately $9.1 billion. The per capita amount was $9,088, which represents a 11.2% year-over-year increase. The 11.2% per capita increase is significant, but this figure reflects Delaware’s health care market rebounding from the reduction in health care spending and utilization in Calendar Year 2020 caused by the COVID-19 pandemic.
The quality results for 2021 were similar to 2020. While Delaware made progress in some important measures, the report shows us there is still significant work to be done to improve the health of Delawareans in other areas.
Overview of Quality Results:
- Adult obesity: The benchmark for 2021 was to reduce the percentage of Delaware adults who are obese to 28.7%. The 2021 result: 33.9%; a decrease from 2020, but still 5.2 percentage points higher than the benchmark.
- Use of opioids at high dosages: The 2021 benchmark: 11.6%; the 2021 result: 9.6%. This is a positive observation.
- Opioid-related overdose deaths: The benchmark for 2021 was to reduce the mortality rate to 14.7 deaths per 100,000. The 2021 result: 48.1 deaths per 100,000. This is an increase from 2020.
- Emergency department utilization: The benchmark for 2021 was to reduce Emergency department utilization to 178 visits per 1,000. The 2021 result: 163 visits per 1,000. This is a positive observation.
- Persistence of beta-blocker treatment after a heart attack: The benchmark rate for 2021 was to increase the percentage of patients who receive beta-blocker treatment to 87.2% of commercial insurance patients and to 83.1% for Medicaid patients. The 2021 results: 88.5% for commercial insurance patients and 80.7% for Medicaid patients. While the Medicaid patients did not reach the benchmark, this is an improvement from the 2020 results of 78.1%.
- Statin therapy for patients with cardiovascular disease: The benchmark rate for 2021 was to increase the percentage of patients who receive statin therapy to 81.0% of commercial insurance patients and 63.8% for Medicaid patients. The 2021 results: 81.8% for commercial insurance patients; 66.1% for Medicaid patients. For both markets, results were better than the respective benchmark. To learn more about the health care spending and quality benchmarks, visit the Health Care Commission website.
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